- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.80 / $1,046.25 / $1,046.25
| Professional | | $1,034.80 | $1,046.25 | $1,046.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.40 / $1,094.38 / $3,132.76
| Professional | | $928.40 | $1,094.38 | $3,132.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.87 / $1,501.02 / $1,961.08
| Professional | | $960.87 | $1,501.02 | $1,961.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.37 / $1,302.35 / $1,961.08
| Professional | | $909.37 | $1,302.35 | $1,961.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.74 / $1,231.72 / $3,580.70
| Professional | | $1,016.74 | $1,231.72 | $3,580.70 |